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Open Access Research article

What they fill in today, may not be useful tomorrow: Lessons learned from studying Medical Records at the Women hospital in Tabriz, Iran

Faramarz Pourasghar124*, Hossein Malekafzali3, Alireza Kazemi1, Johan Ellenius1 and Uno Fors1

Author affiliations

1 Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institute, Stockholm, Sweden

2 Tabriz University of Medical Sciences, Tabriz, Iran

3 Faculty of Public Health, Tehran University of Medical Sciences, Tehran, Iran

4 National Public Health Management Center (NPMC), Iran

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Citation and License

BMC Public Health 2008, 8:139  doi:10.1186/1471-2458-8-139

Published: 27 April 2008

Abstract

Background

The medical record is used to document patient's medical history, illnesses and treatment procedures. The information inside is useful when all needed information is documented properly. Medical care providers in Iran have complained of low quality of Medical Records. This study was designed to evaluate the quality of the Medical Records at the university hospital in Tabriz, Iran.

Methods

In order to get a background of the quality of documentation, 300 Medical Records were randomly selected among all hospitalized patient during September 23, 2003 and September 22, 2004. Documentation of all records was evaluated using checklists. Then, in order to combine objective data with subjective, 10 physicians and 10 nurses who were involved in documentation of Medical Records were randomly selected and interviewed using two semi structured guidelines.

Results

Almost all 300 Medical Records had problems in terms of quality of documentation. There was no record in which all information was documented correctly and compatible with the official format in Medical Records provided by Ministry of Health and Medical Education. Interviewees believed that poor handwriting, missing of sheets and imperfect documentation are major problems of the Paper-based Medical Records, and the main reason was believed to be high workload of both physicians and nurses.

Conclusion

The Medical Records are expected to be complete and accurate. Our study has unveiled that the Medical Records are not documented properly in the university hospital where the Medical Records are also used for educational purposes. Such incomplete Medical Records are not reliable resources for medical care too. Some influencing factors external to the structure of the Medical Records (i.e. human factors and work conditions) are involved.